Rev Bras Cir Cardiovasc 2009; 24(1): 101-102
Letters to the Editor
Cardiomyoplasty
Dear Mr. Editor
It is undeniable that we are living in a time of change of
the heart surgery. With the maturity reached by the fiftieth
anniversary of this speciality, we realize that some cycles
have occurred. Despite the immeasurable progress and
substantial improvement of outcomes in all types of heart
surgery procedures, a clinical entity still needs our deepest
attention, that is the heart failure syndrome. This is clear in
the European Journal of Cardio-Thoracic Surgery of
February (vol 35, No. 02, 2009), on which the first six articles
deal with heart failure, starting with the editorial and
culminating with an article about the management of
diastolic heart failure in cardiac surgery. Mainly, it starts
with cardiomyoplasty. And cardiomyoplasty is the reason
I write this letter. I mean, due to the editor of our Journal.
When watching the lectures of PhD Professor Domingo M.
Braile about heart failure, we always have heard and still
hear the message about the fact that cardiomyoplasty was
neglected early and that it could be an interesting option.
We enter in a cycle of modern approach to heart failure
patients, on which the treatment must be multidisciplinary
and requires full cooperation between surgeons and
cardiologists. A number of innovative options are being
implemented, such as cell therapy and ventricular assist
devices, however, there is a considerable contingent of
patients who may have better quality of life and increased
survival with existing procedures on which we surgeons
are trained: CABG, replacement and valve repair, ventricular
reconstruction, and resynchronization therapy after heart
transplantation.
Another almost immeasurable amount of patients will
have no option. Either by stagnancy in the number of organ
donors or the high mortality on the waiting list or, finally,
the limitations and contra-indications to heart
transplantation. Due to the greater involvement of surgeons
in heart failure programs, the greatest knowledge of imaging
methods, better care of patients and major advance in terms
of electrophysiology make us believe that cardiomyoplasty
will return. Twenty five years after the initiation of
cardiomyoplasty, we have strong reasons to invest in this
technique: 1) new concepts in preservation and muscle
stimulation, 2) maturity of indications and contra-
indications, 3) overcome in resynchronization therapy, 4)
the use of associated implantable defibrillators; 5) the
urgent need for alternatives to transplantation, 6) the cost,
and the insoluble problems with the anti-clotting and the
RBCCV 44205-1063
ventricular assist devices infection.
Thanks to PhD Professor Braile for allowing us to view
more distant horizons.
Gustavo Calado A Ribeiro, Campinas-SP
The Stretchers from Emergency Room (ER)
In July 1990, Professor Adib Jatene wrote on Folha de
São Paulo: “The ER of the Clinics Hospital always has more
patients on stretchers than in bed”.
This fact, reported by the press, resulted in the
superintendent’s resignation, as written by him.
In the article from 1990, he describes the dedication of a
nursing assistant - Joaninha - true symbol of the Clinics
Hospital’s employees.
The number of stretchers, as usual, was greater than
beds. And he recalls that he imediatly felt what the ER
stretchers mean.
Despite the dedication of many Joaninhas, the ER
stretcher is a symbol and a libel: symbol of the unequal
struggle of Health personnel to meet those suffering.
Symbol of fraternity and solidarity, who does not hesitate
to assist, even under unfavorable conditions, and does
not surrender, stands, waits, believes and acts with the
braveness of those who fulfills a mission, not a timetable.
Symbol of dignity, who does not reject the charity and
donates his own work, not to the Government, but to the
patient, while claims to this same Government. Libel against
the indifference, the inability of this Government to solve
the problem and the lack of political will and humanity,
because the Government does not sorely feel the social
problems.
In Brazil, we are used to find the culprits, and not to
offer solutions, that is what we need now.
More than one hundred years ago, Dr. João Penido, in
Minas, addressed his colleagues and authorities during a
cholera epidemic that threatened the city, assuming that
the news was true, but he did not have resources to solve
the problem. Any costs, any measures, all medicines,
depended on the central government. Thus, the alternative
of Municipal Councils was to request all through the
Provincial Assembly but they were not met at all.
The situation is still actual. The SUS was created under
municipal basis. The Constitution and health legislation
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are progressive, but stiffened bureaucracy obstructs the
advancement of decent and quality public services. The
law is not fulfilled, the plans are disrespected, the projects
are stopped (see University Hospitals, in permanently
unfinished works and totally damaged inside). Competent
technicians are changed by patronized politicians.
Nineteen years have passed since the article by Dr. Adib
was published. Has anything changed?
Yes, things have changed for worse. Why it has to be?
The establishment of SUS under public basis - was only
in the speech. Nineteen years old, my dear teacher, and
what do we have?
A post-mature SUS from incubator, with urgent need for
oxygen, warm and much support. Joaninhas’s dedication
and affection to help it to survive.
The difficulties have worsened: the ER stretchers
became the ER floor. The series of problems increased the
viability of the sector. Low sequential investment leads
directly to three consequences: damage of what already
exists in the sector, real impossibility of greater control and
efficiency increasingly far.
While the Federal Government constitutionally extended
the number of citizens with universal right to health,
resources have diminished and SUS beneficiaries have
multiplied by five.
Uncrossing lines were crossed; misdirection lines led
to chaos: the decreasing line of the spent resources,
wrongly used or stolen from Ministry of Health
(“Sanguessugas”, “Mensalão”, ambulances and others)
with the upward line of the number of people with “right”
to health resources - especially to ER.
Another key point in Health is human resources subject.
When speaking about salary, there is no limit and serious
distortions in the salary of the Health personnel. And salary
is not the primary issue. The issue involves working
conditions, technical, human and social training as well.
It is essential to establish the profissional in only one job,
with appropriate salary and decent conditions, what certainly
will help on improving the quality of services with lower costs.
Simple and autonomous organizations are needed, with
statistical informations (costs, production and quality of
services), as the main tool of social control, aiming at greater
transparency in the services management. The directors
should not implore for a simple change of a bored barrel.
The approach model to ensure health should
undoubtedly be revised, but enough about pompous and
demagogic discourse! It is not acceptable that we have to
suffer with the “strokes” (human suffering linked to greater
financial expenses) when resources and time to the effective
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Rev Bras Cir Cardiovasc 2009; 24(1): 101-102
control of blood pressure and its controllable causes were
not spent.
It should not be discussed a medicine for poor people,
but a streamline of the global focus on health.
The ER stretchers from 1990 to 2009.
My dear professor, the battle is inglorious but we have
not lost the hope yet (Until when?), because there are today
- 19 years later – Joaninhas who maintain lighted that flame
of fraternity, equality and freedom.
The great revolution that SUS intends to do in health is
a human resources management, health policy and
financing.
There are enemies of this system: those who lost or
lose with its true establishment and all those who profit
with its inefficiency. However, the Brazilian citizens will be
the most jeopardized.
We need, as noted by Professor Jatene 19 years ago,
“combine more efforts attempting to solve this problem
that has been lasting for decades”, stop finding culprits
but offer solutions. Because, until when can we rely only
on Joaninhas who, with their love and dedication, thank
God, save lives?
Alexandre Brick, Brasília/DF
Multidisciplinary approach
Dear Dr. Braile,
We read with great interest the review of “Renault JA et
al. Respiratory physiotherapy in the pulmonary
dysfunction after cardiac surgery. Rev Bras Cir
Cardiovasc.2008:23 (2)”. It is an admirable manuscript that
aimed at physiotherapy maneuvers on patients undergone
heart surgery, which further highlights the importance of
multidisciplinary work.
Undoubtedly, such quality articles contribute to the
growth of this important mean of intellectual activities
transcription, in addition to the international reach.
We congratulate all the editorial board for the initiative
and accomplishment of a journal with inter- and
transdisciplinary focusing on cardiovascular surgery area.
Regards,
Vitor Engrácia Valenti, Luiz Carlos de Abreu – São
Paulo/SP